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NEW ENGLA ND JOURNAL
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Perspective
july 17, 2014
Toward More Comprehensive Food Labeling
David A. Kessler, M.D.
T
he Food and Drug Administration (FDA) is proposing to revise the Nutrition Facts label that
must appear on virtually all packaged foods in the
United States. The agency’s proposals are strong,
urgently needed, and likely to
make an important contribution
to consumer behavior. But I believe they don’t go far enough —
additional labeling requirements
can do more to influence food
choices, reduce obesity, and promote health.
More than two decades ago,
during my tenure as FDA commissioner, our team had the opportunity to design the nowiconic Nutrition Facts label, which
was mandated by Congress in
the Nutrition Labeling and Education Act of 1990.1 The law gave
the FDA the authority to require
food manufacturers to list the
amounts of fat, cholesterol, sodium, carbohydrate, and protein
contained in their products and
to place those amounts in the
context of a typical daily diet (by
task, considering that we needed
to present standardized information on many thousands of products, from candy bars to cereal
boxes to frozen dinners. And we
had to reach busy shoppers facmeans of the “% Daily Value”), ing aisles and aisles of choice (a
on the basis of realistic serving grocery store carries, on average,
sizes. The agency was also re- almost 43,000 items, according to
quired to develop standards for the Food Marketing Institute2).
health claims such as “lite” and
We eventually developed a label
“low sodium.”
of such clarity that it won the
We understood then that re- Presidential Award for Design
ducing the incidence of diet-­ Excellence in 1997. The design is
related disease and associated specified in great detail, from
mortality was one of the most typeface and size to color (often
significant contributions we could stark black and white) to the
make to public health. Our goal width of the lines used to sepawas not to dictate behavior, but to rate information. A majority of
give people accurate, easy-to-read consumers have said that they
information that encouraged them use the label when they shop.3
to make healthier food choices.
The FDA’s proposed updates
Nothing in the legislation to the Nutrition Facts label represpecified what the label should sent the first significant revision
look like, but we knew that it since its launch and provide a
had to employ the science of critical opportunity to influence
graphic design to nudge behavior. the course of the obesity epidemIn the lingo of marketers, it had ic.4 Over the past decade, we
to “pop.” That was not an easy have learned a great deal about
n engl j med 371;3 nejm.org july 17, 2014
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193
PERS PE C T IV E
Toward More Comprehensive Food Labeling
Nutrition Facts
8 servings per container
Serving size
2/3 cup (55g)
Amount per 2/3 cup
230
Calories
% DV*
12% Total Fat 8g
5%
Saturated Fat 1g
Trans Fat 0g
0% Cholesterol 0mg
7% Sodium 160mg
12% Total Carbs 37g
14%
Dietary Fiber 4g
Sugars 1g
Added Sugars 0g
Protein 3g
10% Vitamin D 2 mcg
20% Calcium 260 mg
45% Iron 8 mg
5% Potassium 235 mg
* Footnote on Daily Values (DV) and calories
reference to be inserted here.
Figure 1. The FDA’s Proposed New
Nutrition Facts Label.
the reinforcing properties of sugar
and how they promote overeating,
and we know that people tend to
consume calorie-rich, sugary products at the expense of nutrientdense foods. The Department of
Agriculture’s Dietary Guidelines
urge Americans to limit their
consumption of “added sugar”
— sugar that is added to foods
during processing or preparation
rather than being intrinsic to it
(as it is in fruit).
To support that recommendation, the FDA’s proposal would
require manufacturers to indicate how much sugar they add to
a food, distinguishing it from
the total sugar that is present. It
would also revise serving sizes so
that calorie counts and nutrient
levels more accurately reflect what
people actually eat, and it would
feature that information much
more prominently (see Fig. 1). The
goal is to grab the consumer’s
attention enough to influence
behavior.
194
An omission in the current
proposals is a Daily Value for added sugar, which would let consumers quickly see whether a food
is low or high in added sugars.
But in general, the FDA is taking
some very important, sciencebased steps.
What the proposals don’t do
is consider a product’s overall
nutritional value. There is nothing in the new framework that
actively encourages consumers to
purchase food rich in the fruits,
vegetables, and whole grains that
are rightfully considered “real
food.” Instead, the focus is on
specific nutrients — an emphasis that gives food companies an
incentive to fortify their products
so they can make claims such as
“added fiber” or to produce sugarladen foods that can be labeled
“low fat.”
Beyond refreshing the Nutrition Facts label, I believe that the
FDA needs a larger strategy to
influence the food environment
and to support the admonishment
based on the Dietary Guidelines
to “make half your plate fruits
and vegetables.”
Overhauling the ingredient list,
which manufacturers are obligated to provide in descending order by weight, certainly belongs
on the agenda. Tiny type, complex names, and confusing formats make many ingredient lists
almost impossible to read or understand. Incorporating smart design into those lists is a commonsense requirement.
In addition, product manufacturers should have to aggregate
related ingredients. At present,
they can list different sweeteners
separately — pushing ingredients
such as fructose, corn syrup,
dextrose, sucralose, brown rice
syrup, and maltodextrin to lower
positions on the list. If we instead defined all forms of sugar
as a single ingredient, sugar might
emerge near the top of many
products’ lists.
We also need front-of-package
labeling that we can trust. Historically, the industry has claimed
the front for promoting its products, and the FDA has accepted
that convention, with regulated
labeling confined to the side or
back of a package. But there is
no reason that acceptance should
stand. Indeed, the Institute of
Medicine and the FDA have
worked together in the past to
develop some tough front-ofpackage proposals, but these efforts stalled after a self-protective
industry offered a paler voluntary
labeling strategy known as Facts
Up Front.5
A stronger approach would require that the top three ingredients, the calorie count, and the
number of additional ingredients
be listed on the front of every
package in bold, easy-to-read type
(see Fig. 2). To the harried shopper hoping to make some healthy
choices, it would offer a quick
way of identifying high-calorie,
obesity-inducing food and of
finding healthier alternatives. Because the number of ingredients
in a product often reflects the
substitution of chemical additives
for the flavor of real food, labels
reading “+5 more ingredients” or
“+20 more ingredients” would be
informative shorthand.
Far from being fully fleshedout proposals, the ideas sketched
here are only a starting place for
the complex process that I hope
will move the FDA from an initial proposal through public commenting and into regulations.
Whatever form those regulations
ultimately take, their goal should
be to encourage the sale and
consumption of products full of
fruits, vegetables, and whole
grains, rather than those loaded
n engl j med 371;3 nejm.org july 17, 2014
The New England Journal of Medicine
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Copyright © 2014 Massachusetts Medical Society. All rights reserved.
PE R S PE C T IV E
Toward More Comprehensive Food Labeling
iStockphoto.com/padnpen/Kevin Grady/Elizabeth Drye
Figure 2. Possible New Front-of-Package Labeling.
with little more than fat, sugar,
and salt.
That won’t be easy. The food
industry is expert at promoting
its food in a captivating manner,
so the FDA has very heavy competition for the consumer’s eye.
But we are riding a tide of
change, with obesity experts increasingly recognizing the value
of healthy eating and consumers
eager to make smarter food
choices. A revised Nutrition Facts
label combined with a streamlined, comprehensible ingredient
list and trustworthy front-ofpackage labeling can have a
powerful impact not only on consumer behavior, but perhaps more
important, on the decisions manufacturers make about the foods
they create for the marketplace.
Disclosure forms provided by the author
are available with the full text of this article
at NEJM.org.
From the Departments of Pediatrics and
Epidemiology and Biostatistics, School of
Medicine, University of California, San Francisco, San Francisco.
1. Kessler DA, Mande JR, Scarbrough FE,
Schapiro R, Feiden K. Developing the “nutrition facts” food label. Harvard Health
Policy Review 2003;4:13-24 (http://www.hcs
.harvard.edu/~epihc/currentissue/fall2003/
kessler_et_al.pdf).
2. Supermarket facts: industry overview
2012. Arlington, VA: Food Marketing Institute
(https://www.fmi.org/research-resources/
supermarket-facts).
3. Todd JE, Variyam JN. The decline in consumer uses of food nutrition labels, 1995-2006.
Washington, DC: Department of Agriculture
Economic Research Service, August 2008.
4. Proposed changes to the Nutrition Facts
label. Silver Spring, MD: Food and Drug
Administration (http://www.fda.gov/Food/
GuidanceRegulation/GuidanceDocuments
RegulatoryInformation/LabelingNutrition/
ucm385663.htm).
5. Nestle M. IOM releases tough report on
front-of-package labeling. Food Politics blog,
October 20, 2011 (http://www.foodpolitics
.com/2011/10/iom-releases-tough-report-on
-front-of-package-labeling).
DOI: 10.1056/NEJMp1402971
Copyright © 2014 Massachusetts Medical Society.
Nutrient-Content Claims — Guidance or Cause
for Confusion?
Allison C. Sylvetsky, Ph.D., and William H. Dietz, M.D., Ph.D.
N
utrient-content claims, such
as “sugar-free,” “high in oat
bran,” or “contains 100 calories”
— any “claims on a food product that directly or by implication characterize the level of a
nutrient in the food” — are reg-
ulated in accordance with specific requirements of the Food
and Drug Administration (FDA).
According to the 2000–2001
Food Label and Package Survey
(FLAPS), half of all packaged
foods and beverages sold in the
n engl j med 371;3
nejm.org
United States presented such
nutrient-content claims.1 The prevalence of these claims has increased in recent years,2 as the
food and beverage industry has
launched myriad new products
to offer palatable, lower-calorie
july 17, 2014
The New England Journal of Medicine
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Copyright © 2014 Massachusetts Medical Society. All rights reserved.
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